Hindawi

International Scholarly Research Notices

Volume 2017, Article ID 2636759, 5 pages
https://doi.org/10.1155/2017/2636759

Research Article
Acute Appendicitis in Pregnancy and the Developing World

Tika Ram Bhandari,1 Sudha Shahi,2 and Sarita Acharya3

1
Department of General Surgery, Universal College of Medical Sciences, Bhairahawa 32900, Nepal
2
Department of ENT, National Academy of Medical Sciences, Kathmandu 44600, Nepal
3
Department of Obstetrics and Gynecology, Universal College of Medical Sciences, Bhairahawa 32900, Nepal

Correspondence should be addressed to Tika Ram Bhandari; tikanmc@hotmail.com

Received 1 May 2017; Revised 12 June 2017; Accepted 27 June 2017; Published 20 July 2017

Academic Editor: Christos Iavazzo

Copyright © 2017 Tika Ram Bhandari et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

Background. Acute appendicitis is the commonest nonobstetric surgical emergency during pregnancy. The aim of the study
was to compare perioperative outcomes of acute appendicitis in pregnant and nonpregnant patients. Methods. A retrospective
review of medical records of 56 pregnant patients between 2011 and 2016 who were compared with 164 nonpregnant women of
reproductive age who underwent open appendectomy between 2014 and 2016 for acute appendicitis. The patient’s demographics
and perioperative data were analyzed. Results. The median age of pregnant and nonpregnant patients observed was 26 years (range
19–37) and 26 years (range 18–43). There were no significant differences between the groups in negative appendectomy (21.4 and
21.3%, 𝑃 = 0.52), perforated appendicitis (25 and 23.8%, 𝑃 = 0.85), postoperative complications (28.6 and 26.8%, 𝑃 = 0.80),
and median length of hospital stay (5 and 4.5 days, 𝑃 = 0.36). There were 3.6% preterm labour, no maternal mortality, and
no fetal loss. In multivariate analysis, WBC >18000/mm3 and long patient time to surgery were independent risk factors for
appendicular perforation and postoperative complication (𝑃 < 0.05). Conclusion. Our results of appendectomy in pregnant patients
are comparable with nonpregnant patients. Hence the same perioperative treatment protocol can be followed in pregnant and
nonpregnant patients even in resource-poor setting.

1. Introduction outcomes of acute appendicitis in pregnant and nonpregnant

Acute appendicitis is the commonest nonobstetric emergency
requiring surgical intervention in a pregnant patient [1].
Symptoms and signs of pregnancy are variable among the
patients [2, 3]. Abdominal ultrasonography may have a low
accuracy and computed tomography is usually avoided in
pregnancy as much as possible, mostly in the first trimester,
due to hazards of exposure to ionizing radiation [1, 4].
Meanwhile, accurate diagnosis is essential during pregnancy
to reduce negative appendectomy. Delay in diagnosis and
treatment also results in increased risk of developing perfo-
ration which can lead to poor postoperative outcomes [5, 6].
There are only few studies [7, 8] that have been reported from
developing countries about acute appendicitis in pregnant
patients until now. The exact rate of acute appendicitis in
pregnant women is not identified and its management is
imprecise in a developing nation like ours. The aim of this
study was to compare clinical presentation and perioperative
patients in resource-poor setting.
2. Material and Methods
A retrospective review of medical records of 56 consecu-
tive pregnant patients who underwent open appendectomy
between 2011 and 2016 was done. The data was compared with
that of 164 nonpregnant female patients of reproductive age,
who had undergone open appendectomy between 2014 and
2016 at Universal College of Medical Sciences, Bhairahawa,
Nepal. The study was approved by the Institutional Review
Committee of Universal College of Medical Sciences, Bhaira-
hawa, Nepal. The gestational period was categorized as the
first (0–13 weeks), second (14–26 weeks), and third trimester
(27 weeks and beyond). The reproductive age has been
defined between 15 and 49 years according to World Health
Organization (WHO). Time to surgery was defined as the
period from onset of symptoms till surgery. Abnormal WBC
2 International Scholarly Research Notices

was considered less than 4000/mm3 (leukopenia) or more Table 1: Preoperative data.
than 11000/mm3 (leukocytosis). Leucocytosis was again sub-
Pregnant Nonpregnant 𝑃∗ value
divided into less than 18000/mm3 and more than 18000/mm3 Variable
(𝑛 = 56) (𝑛 = 164)
since mild to moderate leukocytosis are features common to
Age (years) 26 (19–37) 26 (18–43) 0.35
both normal pregnancy and acute appendicitis. Temperature
above 37.8∘ C was considered as fever. A diagnosis of acute Comorbidity, % 11 (19.6) 28 (17.1) 0.66
appendicitis was made based on clinical presentation and Cardiovascular disease 1 (6.4) 4 (2.4)
laboratory and radiological findings. Diabetes mellitus 2 (3.6) 5 (3.0)
For patients in earlier weeks of pregnancy, we followed Respiratory diseases 1 (5.1) 3 (1.8)
them up till 30th postoperative day after appendectomy. Anemia 5 (8.9) 10 (6.1)
Surgical outcomes were recorded during that period. After
Hypertension 1 ( 1.8) 3 (1.8)
that the patients followed up on pregnancy outcome in
obstetric department. In case of the patient who had labor Neurological problems 1 (1.8) 3 (1.8)
pain shortly after appendectomy, she was shifted to obstetric Nausea/vomiting 0.72
unit at our hospital and delivery was conducted. Coordi- Yes 38 (67.9) 107 (65.2)
nation with the obstetric team made us easy for follow- No 18 (32.1) 57 (34.8)
up of these patients during perioperative period. Records Fever 0.65
were maintained. The patient’s preoperative, operative details,
Yes 23 (41.1) 73 (44.5)
postoperative outcomes, and pregnancy related outcomes
were analyzed. No 33 (58.9) 91 (55.5)
All continuous variables were expressed as median or Tenderness 0.86
mean ± standard deviation which were compared with Localised 45 (80.4) 130 (79.3)
Mann-Whitney test or independent 𝑡-test, as appropriate. Generalised 11 (19.6) 34 (20.7)
Chi-square test or Fisher’s exact test was used for categorical White blood cell count 0.93
values as appropriate. Perforated appendicitis and postoper-
Normal 21 (37.5) 58 (35.4)
ative complications were the outcome variables in the study.
Multivariate analysis (logistic regression) was considered for <18000/mm3 24 (42.9) 75 (45.7)
those variables that were significant for outcome variable >18000/mm3 11 (19.6) 31 (18.9)
on univariate analysis. All data were analyzed using SPSS Ultrasonography 0.98
version 22.0 for Windows. 𝑃 value < 0.05 was considered as Positive 25 (44.6) 73 (44.5)
statistically significant. Negative 31 (55.4) 91 (55.5)
Categorical variables are presented as
푛 (%); continuous variables are
3. Results presented as median (interquartile range); ∗
푃 value significant if < 0.05.

Fifty-six pregnant patients with median age 26 years (range

19–37) and 164 nonpregnant female patients of reproductive
age with median age 26 years (range 18–43) who underwent
open appendectomy for acute appendicitis during the study
period were studied. Out of the 56 pregnant patients, 23
(41.1%) patients had surgery during the first trimester, 26
(46.4%) during the second trimester, and 7 (12.5%) during the
third trimester. Most of the pregnant patients were multipara
36 (64.3%). Right lower quadrant pain of the abdomen
was the most common clinical symptom irrespective of the
gestational period in pregnant patients and nonpregnant
patients. Patient’s preoperative data are shown in Table 1.
There were no significant differences in different preoperative
variables (𝑃 > 0.05), when we compared these variables in
pregnant and nonpregnant patients.
When we compared different intraoperative and post-
operative variables in pregnant and nonpregnant patients,
we did not find any significant differences in mean time to
surgery, mean operative time, perforated appendicitis, the
rate of complications, and negative appendectomy between
the pregnant and nonpregnant groups (𝑃 > 0.05) which are
shown in Table 2. The overall postoperative complications
observed between the groups were 28.6 and 26.8%. Surgical
site infection was the most common complication in both
groups (14.3 and 13.4%). The pregnant patients had slightly
longer median duration of hospital stay than the nonpregnant
patients (5 and 4.5 days); however it was not statistically
significant (𝑃 = 0.33). There was no mortality in either of
the groups. Preterm labor occurred in 2 (3.6%) patients while
postoperative fetal loss was not observed in our study.
There was no association of pregnancy status of patient
with appendicular perforation and postoperative compli-
cations in acute appendicitis (𝑃 > 0.05). However, in
multivariate analysis WBC > 18000/mm3 and patients time
to surgery (onset of symptoms to surgery) were independent
risk factors for appendicular perforations (OR: 47.9; 95% CI
[13.68–168]; 𝑃 = 0.001 and OR: 6.57; 95% CI [2.27–19.5];
𝑃 = 0.001) and for postoperative complications (OR: 11.1; 95%
CI [4.09–30.4]; 𝑃 = 0.001 and OR: 3.53; 95% CI [1.49–8.34];
𝑃 < 0.05), respectively.
4. Discussion
There is a paucity of data on acute appendicitis in pregnant
patients from developing nations. Most of the previous stud-
ies stated that acute appendicitis presents atypically during
pregnancy [9] and deserves an aggressive operative approach
to prevent perforation and increased risk of poor outcomes
[10]. However, recent upgrade in the precision of diagnostic
International Scholarly Research Notices 3

Table 2: Intraoperative and postoperative data.

Variable Pregnant Nonpregnant 𝑃∗ value

(𝑛 = 56) (𝑛 = 164)
Time to surgery (hours) 36 (12–70) 30 (6–70) 0.28
Time to surgery (>48 hours) 18 (32.1) 51 (31.1) 0.88
Operative time (minutes) 50 (30–80) 50 (30–80) 0.19
Operative time (>60 minutes) 7 (12.5) 14 (8.5) 0.38
Pathology 0.52
Normal 12 (21.4) 35 (21.3)
Inflamed 15 (26.8) 41 (25.0)
Suppurative 26 (46.4) 78 (47.6)
Gangrenous 3 (5.4) 10 (6.1)
Perforation
Yes 14 (25.0) 39 (23.8) 0.85
No 42 (75.0) 125 (76.2)
Complications% 16 (28.6) 44 (26.8) 0.80
SSIQ 8 (14.3) 22 (13.4)
LRTI¶ 4 (7.1) 7 (4.3)
UTI† 2 (3.6) 7 (4.3)
Intraabdominal abscess 1 (1.8) 4 (2.4)
Superficial thrombophlebitis 1 (1.8) 4 (2.4)
Length of hospital stay (days) 5 (3–14) 4.5 (3–18) 0.36
Categorical variables are presented as
푛 (%); continuous variables are presented as median (interquartile range); Q SSI: surgical site infection; ¶ LRTI: lower
respiratory tract infection; † UTI: urinary tract infection; ∗
푃 value significant if <0.05.

radiological modalities and the effectiveness of antibiotic
treatment has made the old approach questionable.
Several studies have reported the prevalence of acute
appendicitis in pregnant population to be 0.06% to 0.28%
[11, 12]. We found the incidence 1/800 (0.12%) of acute appen-
dicitis during pregnancy which was comparable with other
studies. Similar to what has been reported in the literature,
most of our patients were in the second trimester [13].
However, Davoodabadi et al. [14] found that the incidence
of acute appendicitis during pregnancy was high during the
third trimester. The second trimester is considered as the
most appropriate time for appendectomy and this period
has the lowest risk for fetus from operation and anesthesia.
Though the first trimester is the best time with respect to ease
of operation, this time may be risky for the fetus. The third
trimester is considered as the poorest time with respect to
operative comfort and hazards of preterm birth. The median
age of 26 years, in our study, is lower than that reported
by some other studies [5, 15]. This could be due to an early
marriage and early childbearing age in our part of the world
as compared to the developed countries.
In our study, abdominal pain was the commonest symp-
tom (100%) as reported by another study [16]. The pain
typically migrates to the right iliac fossa and worsens when
the patient coughs.
Usually pregnancy is related to leukocytosis in a healthy
female, which is associated with increased number of neu-
trophils. In the second month of gestation, the neutrophil
count starts to increase and plateaus in the second or third
trimester. During that time the total leucocyte counts range
from 10000 to 15,000/mm3 [14]. The current study reported
62.5% of abnormal leukocyte count which is in concor-
dance with what was reported by Hiersch et al. [17]. There
were no significant differences in WBC between the groups
during admission. Ultrasonography may show distended
nonperistaltic blind ended tubular structure appendix, but
the appendix is seen in only 25–59% of patients with acute
appendicitis. However, it is supportive in making diagnosis
and exclusion of some other diseases [18]. In our series, acute
appendicitis was detected in 44.6 and 44.5% of pregnant and
nonpregnant patients by ultrasonography, respectively.
We reported negative appendectomy (21.4 and 21.3%, 𝑃 =
0.52) similar to the negative appendectomy rate mentioned
in the literature (23–50% and 15–35%) for a pregnant or
nonpregnant cohort [19]. However, Zingone et al. specified
17.4% of negative appendectomy in their large population-
based study [20].
There was no difference in the rate of perforated appen-
dicitis between the pregnant and nonpregnant patients (25.0
and 23.8%, 𝑃 = 0.85). The proportion of appendicular
perforation in our study (25%) is higher than that previously
reported [21]. It might be because our patients presented
very late to the hospital thus delaying timely diagnosis and
treatment [22]. Also, most of our patients were in the second
or third trimester (58.9%). With growing gestational age
diagnostic correctness decreases and is related to increased
rates of appendiceal perforation and therefore postoperative
complications.
4 International Scholarly Research Notices
We did not find any differences in postoperative compli-
cations between the groups (28.6 and 26.8%, 𝑃 = 0.80). The
complication rate 28.6% that we have found in pregnancy
was comparable to those shown by other studies [23]. No
maternal and fetal mortality was observed in spite of the
high rate of perforation and high rate of complications.
Improvement in maternal survival may be due to the use of
antibiotics, improved anesthesia, and better care. However, a
study reported 4-5% fetal loss rate after surgery [19]. Many
studies have mentioned preterm delivery rate in pregnant
patients with appendicitis up to 11.4% [24]. Two of our
patients had preterm deliveries at 36th week of gestational
age. Preterm labor occurred in the fourth and fifth hour
of surgery, respectively, and both patients later underwent
normal vaginal deliveries giving birth to healthy babies. It
has been mentioned that the performance of any surgery
during pregnancy increases the risk of premature labor by
10–15%. Both our patients had preterm delivery during the
postoperative period after appendectomy while they were
still in the hospital. So, there seems to be some association
between preterm delivery and surgery in our cases also. In
the present study we had only 3.6% (95% confidence interval;
0.4–12.3%) of preterm deliveries; this could be due to small
(56 pregnant patients) study population.
We also analyzed the factors that affected perforation
of the appendix and postoperative complications in acute
appendicitis including pregnancy status of patient. However,
we did not find that pregnancy status of patient had any
influence. However we observed that, besides long patient
time to surgery, WBC > 18000/mm3 was a risk factor
associated with appendicular perforation and postoperative
complications. This agrees with what has been reported in
the literature [25, 26] even though some studies described no
association between patient time to surgery and perforation
[27].
As we are based in the developing world, we have to
face several problems like scarcity of trained manpower and
training opportunities, frequent usage of disposable surgical
tools, shortage of funds to preserve equipment, and poor
postoperative care. Besides that, due to poor economy, poor
transportation services, and long distances in rural setting,
the general public often have poor access to medical services.
Mostly our patients and their families hesitate regarding the
safety of surgery during pregnancy and do not realize the
advantage due to lack of medical knowledge, poor education,
and social stigma.
Regardless of all, we believe that this is the first descriptive
comparative study of acute appendicitis in a pregnant and a
nonpregnant cohort in the developing world. The limitations
of our study were a retrospective, single centered design
and small pregnant study population. The study and control
groups were identified within two different time periods,
2011–2016 for study group and 2014–2016 for the control
group which may have caused a bias. We acknowledge our
limitation of not being able to compare certain preoperative
data like BMI which was not mentioned in medical records of
patients. Therefore, in order to verify our findings, additional
appropriately designed prospective study in the developing
world is suggested.
5. Conclusion
We did not find any differences in clinical presentation and
postoperative outcomes of acute appendicitis in pregnant and
nonpregnant patients. Hence similar perioperative treatment
protocol can be followed for pregnant and nonpregnant
groups even in resource-poor setting.
Conflicts of Interest
The authors declare that there are no conflicts of interest
regarding the publication of this paper.
Authors’ Contributions
All the authors contributed equally to drafting, literature
search, and writing
References
[1] B. Andersen and T. F. Nielsen, “Appendicitis in pregnancy:
diagnosis, management and complications,” Acta Obstetricia et
Gynecologica Scandinavica, vol. 78, no. 9, pp. 758–762, 1999.
[2] R. I. Mazze and B. Källén, “Appendectomy during pregnancy: a
swedish registry study of 778 cases,” Obstetrics and Gynecology,
vol. 77, no. 6, pp. 835–840, 1991.
[3] S. Jung, D. K. Lee, J. H. Kim, P. S. Kong, K. H. Kim, and S.
W. Bae, “Appendicitis during pregnancy: the clinical experience
of a secondary hospital,” Journal of the Korean Society of
Coloproctology, vol. 28, no. 3, pp. 152–159, 2012.
[4] N. Abbasi, V. Patenaude, and H. A. Abenhaim, “Evaluation of
obstetrical and fetal outcomes in pregnancies complicated by
acute appendicitis,” Archives of Gynecology and Obstetrics, vol.
290, no. 4, pp. 661–667, 2014.
[5] L. Segev, Y. Segev, S. Rayman, A. Nissan, and E. Sadot, “Acute
appendicitis during pregnancy: different from the nonpregnant
state?” World Journal of Surgery, vol. 41, no. 1, pp. 75–81, 2016.
[6] K. Atila, A. D. Uçar, T. Unek, A. Sevinç, A. A. Cevik, and S.
Sökmen, “Acute appendicitis in pregnancy,” Turkish Journal of
Trauma & Emergency Surgery, vol. 8, no. 2, pp. 98–101, 2002.
[7] A. Ghazanfar, S. M. Nasir, Z. A. Choudary, and W. Ahmad,
“Acute appendicitis complicating pregnancy; experience with
the management of 50 patients,” Journal of Ayub Medical
College, Abbottabad: JAMC, vol. 14, no. 3, pp. 19–21, 2002.
[8] S. F. Kazim and K. M. Inam Pal, “Appendicitis in pregnancy:
experience of thirty-eight patients diagnosed and managed at
a tertiary care hospital in Karachi,” International Journal of
Surgery, vol. 7, no. 4, pp. 365–367, 2009.
[9] A. H. Franca Neto, M. M. Amorim, and B. M. Nóbrega,
“Acute appendicitis in pregnancy: literature review,” Revista da
Associação Médica Brasileira, vol. 61, no. 2, pp. 170–177, 2015.
[10] S. Maslovitz, G. Gutman, J. B. Lessing, M. J. Kupferminc, and
R. Gamzu, “The significance of clinical signs and blood indices
for the diagnosis of appendicitis during pregnancy,” Gynecologic
and Obstetric Investigation, vol. 56, no. 4, pp. 188–191, 2003.
[11] R. E. B. Andersson and M. Lambe, “Incidence of appendicitis
during pregnancy,” International Journal of Epidemiology, vol.
30, no. 6, pp. 1281–1285, 2001.
[12] H. Al-Dahamsheh, “Suspected appendicitis during pregnancy:
prevalence and management at prince Hashem Ben AL-Hussein
International Scholarly Research Notices 5

Hospital (Zarqa/Jordan),” Journal of College of Medical Sciences-

Nepal, vol. 8, no. 1, pp. 36–43, 2012.
[13] T. Ueberrueck, A. Koch, L. Meyer, M. Hinkel, and I. Gastinger,
“Ninety-four appendectomies for suspected acute appendicitis
during pregnancy,” World Journal of Surgery, vol. 28, no. 5, pp.
508–511, 2004.
[14] A. Davoodabadi, H. Davoodabadi, H. Akbari, and M. Janza-
mini, “Appendicitis in pregnancy: presentation, management
and complications,” Zahedan Journal of Research in Medical
Sciences, vol. 18, no. 7, Article ID e7557, 2016.
[15] P.-L. Wei, J. J. Keller, H.-H. Liang, and H.-C. Lin, “Acute
Appendicitis and Adverse Pregnancy Outcomes: A Nationwide
Population-Based Study,” Journal of Gastrointestinal Surgery,
vol. 16, no. 6, pp. 1204–1211, 2012.
[16] G. Masselli, L. Derchi, J. McHugo et al., “Acute abdominal and
pelvic pain in pregnancy: ESUR recommendations,” European
Radiology, vol. 23, no. 12, pp. 3485–3500, 2013.
[17] L. Hiersch, Y. Yogev, E. Ashwal, A. From, A. Ben-Haroush, and
Y. Peled, “The impact of pregnancy on the accuracy and delay in
diagnosis of acute appendicitis,” Journal of Maternal-Fetal and
Neonatal Medicine, vol. 27, no. 13, pp. 1357–1360, 2014.
[18] K. F. Borushok, R. B. Jeffrey Jr., F. C. Laing, and R. R. Townsend,
“Sonographic diagnosis of perforation in patients with acute
appendicitis,” American Journal of Roentgenology, vol. 154, no.
2, pp. 275–278, 1990.
[19] M. L. McGory, D. S. Zingmond, A. Tillou, J. R. Hiatt, C. Y.
Ko, and H. M. Cryer, “Negative appendicectomy in pregnant
women is associated with substantial risk of fetal loss,” Journal
of the American College of Surgeons, vol. 205, no. 4, pp. 534–540,
2007.
[20] F. Zingone, A. A. Sultan, D. J. Humes, and J. West, “Risk of
acute appendicitis in and around pregnancy a population-based
cohort study from england,” Annals of Surgery, vol. 261, no. 2, pp.
332–337, 2015.
[21] C. C. Kilpatrick and M. Monga, “Approach to the acute
abdomen in pregnancy,” Obstetrics and Gynecology Clinics of
North America, vol. 34, no. 3, pp. 389–402, 2007.
[22] N. A. Bickell, A. H. Aufses Jr., M. Rojas, and C. Bodian, “How
time affects the risk of rupture in appendicitis,” Journal of the
American College of Surgeons, vol. 202, no. 3, pp. 401–406, 2006.
[23] K. Ito, H. Ito, E. E. Whang, and A. Tavakkolizadeh, “Appen-
dectomy in pregnancy: Evaluation of the risks of a negative
appendectomy,” American Journal of Surgery, vol. 203, no. 2, pp.
145–150, 2012.
[24] E. C. Gregory and M. F. MacDorman, “Fetal and perinatal
mortality: United States, 2013,” National Vital Statistics Reports,
vol. 64, no. 8, pp. 1–24, 2015.
[25] H. G. Yilmaz, Y. Akgun, B. Bac, and Y. Celik, “Acute appendicitis
in pregnancy—risk factors associated with principal outcomes:
a case control study,” International Journal of Surgery, vol. 5, no.
3, pp. 192–197, 2007.
[26] L. H. Theilen, V. M. Mellnick, A. L. Shanks et al., “Acute appen-
dicitis in pregnancy: predictive clinical factors and pregnancy
outcomes,” American Journal of Perinatology, vol. 34, no. 6, pp.
523–528, 2017.
[27] M. Tracey, H. S. Fletcher, J. I. Hollenbeck, A. Sardi et al.,
“Appendicitis in pregnancy/discussion,” The American Surgeon,
vol. 66, no. 6, pp. 555–559, 2000.